Provider Demographics
NPI:1174094916
Name:SUNRISE PSYCHOLOGY LLC
Entity type:Organization
Organization Name:SUNRISE PSYCHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MYLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KALTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:321-223-1231
Mailing Address - Street 1:5560 OLD DIXIE HWY UNIT 62
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:FL
Mailing Address - Zip Code:32949-2148
Mailing Address - Country:US
Mailing Address - Phone:321-223-1231
Mailing Address - Fax:
Practice Address - Street 1:101 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-8301
Practice Address - Country:US
Practice Address - Phone:321-984-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health